Sociopolitical development of the nursing profession in Iran: a historical review

Significant sociopolitical changes in recent decades have not only influenced the nursing profession, but also the entire Iranian healthcare system. This study describes the historical evolution of the nursing profession within a sociopolitical context. This historical review of unpublished and published literature endorsed personal accounts of historic events by 14 of the oldest nurses in Iran chosen through purposive sampling method, as they shared their nursing experiences. Individual recollections were collected through in-depth and semi-structured interviews and later analyzed through oral history analysis method. From the results, the 3 categories of the White Revolution, the Islamic Revolution, and Iran-Iraq war and 8 subcategories emerged, where participants identified factors that fundamentally changed the Iranian nursing profession. The nursing profession continues to develop and help revise policies to improve the healthcare system and quality of care. The findings of this study facilitate the better understanding of the influence of sociopolitical events on the nursing profession and guide the revision or development of new healthcare policies.


Introduction
during 1980-1988, which resulted in nursing advances in terms of clinical, educational, and research development (7). Historical changes in the Iranian nursing profession have presented complex social and ethical issues. According to Vaughans, a historic review of events related to the nursing profession can be traced to sociopolitical and cultural issues of the time, worthy of exploration to create ideas, meanings, and interpretations, and critical to the present and future paths in nursing (8). The history of nursing reveals repeated patterns of encountering professional issues over time and in every decade with new strategies to resolve them. Hence, examination of past events provides effective solutions to future challenges (9). The historical research method can link past, present, and future events. Learning about the history of a profession, the process of its development, and its flourishing trends can lead to increased confidence in those associated with the profession. Having historical knowledge of a profession is the cornerstone of professional identity, recognition, and criticism surrounding that profession. Hence, attention to the professional background is necessary. However, as time passes, access to essential resources for deeper understanding of professional identity becomes limited or restricted. Archiving and restoring historical documents are often neglected in developing countries with irreversible losses of learning opportunities. In this study, researchers sought to study and record the history of the Iranian nursing profession and needed access to live witnesses to obtain data from lived experiences and establish records. The present study describes changes and challenges within the Iranian nursing profession from a sociopolitical perspective.

Method
Considering the study objectives, limited access to historical resources and documents, and past library destructions, obtaining oral history from living witnesses of events in Iran provided an opportunity to gain historical reviews and apply the oral history method. The oral history method was first described by Allan Nevins in 1948, and records important events according to recalled lived experiences of study participants. Oral history method refers to the recording of individuals' verbal statements and is recognized as a scientific and regulated method based on theoretical and practical principles for collecting evidence through verbal documents (10). This method can help produce documents after verification, confirmation, and completion with support of other resources, particularly written documents, and is often used by researchers in the fields of history, sociology, and psychology (11). To obtain verbal/oral history, 14 senior and experienced nurses in clinical, educational, managerial, and policymaking areas, who live in several provinces of Iran such as Rasht, Mashhad, Tehran, Yazd, Tabriz, Kermanshah, and Urmia, were recruited to serve as the primary data source during September 2013 to November 2014. Shared lived experiences of participants began from 1937 to 2014. Primary sources were obtained from participants through interviews, personal and professional documents, journals, photographs, and letters. The interviews were tape recorded and the researcher took shorthand notes to document each participant's account in more detail. Secondary sources included newspapers, magazines, relevant articles, books, photographs, governmental documents, and personal archives held at the document conservation centers (the Islamic Revolution Document Center, Library, Museum and Document Center of Iranian Parliament, Central Library of Astan Quds Razavi, and the National Library and Archives of Iran) and medical sciences museums (Tehran University of Medical Sciences and Tabriz University of Medical Sciences, Iran) to support and verify the oral history data. The same dramatic stories happened for our documents. Some of the documents were lost by fire or were taken abroad by nurses who left the country after the Islamic Revolution; some other documents were lost or destroyed during pre-Islamic period in the throes of revolution. Moreover, some historic documents were destroyed in previous wars or disposed by the opposing ruling parties. Therefore, we found gaps in the available documents and found it necessary to supplement certain parts of the historical data through interviews and participant recalls. After obtaining the approval of the Research Deputy of the Ethics Committee at Tehran University of Medical Sciences, the study objectives and procedures were explained to all participants to retrieve signed written informed consent forms. Participant's interviews lasted 45-90 minutes and took place at a location most convenient to them, which included their homes, offices, or a hotel lobby. The oldest living Iranian nurses were selected for participation in this study through purposive sampling. The researchers referred to retirement associations, nursing offices at major universities, and convalescent healthcare facilities to identify suitable participants and interview them. It should be noted that participants were selected to represent a wide variety of past events through maximum variation in age, gender, years of work experience, nursing specialty, professional responsibilities, and place of residence. Semi-structured interviews were continued until data saturation was reached.
Participants were asked open-ended questions to allow for elaborate responses which were followed by probing questions to further expand on the topic. Examples of openended questions used in this studs are : "Please tell me about your nursing experience before and after graduation from the nursing school.", and "Tell me about sour work experience as a nurse." Follow-up and probing questions used were: "According to sour past nursing experience…, what seems to have changed within the last few decades and how has the nursing profession evolved?" Explorators questions and complementary interviews were based on questions such as "Whs do sou think so?" and "Please explain more.", to gain a deeper understanding of the participants' experiences and how they felt about their nursing roles, in order to shed light on the less known aspects of nursing profession in Iran. Data were collected and simultaneously analyzed to form categories and new participants were selected based on data received from previous participants. In total, 17 interviews were conducted with 14 participants for a total of 1,240 minutes.

Data analysis
After the interviews, the recorded data were analyzed using oral history analysis method according to Miller's four level steps for its applicability to the nursing profession (12,13). The data analysis method used in this study begins with writing narratives and consists of 4 stages. The first stage involves interviews, that is, collecting oral testimonies related to the study topic. The second stage is the portrait(s) of meaning are presented through biographies for the initial interpretation and reconstruction of interviews in detail according to changes in the social environment as raw data are transcribed verbatim. At this level, similar concepts are grouped and coded to form subcategories and the process of interpreting and validating the historical statements begins, where researcher(s) incorporate secondary data from books, newspapers, and other historical sources to validate their findings. The third stage is the seeds of meaning. Telling extracts are used at this level to focus on finding the key concepts by cross-analysis through validation of biography. Upon the second review, coded data and subcategories are clustered to develop the main categories. At this stage, researchers will be able to identify any inconsistencies by comparing each expression with the whole data pool for cross validation. Rigor of the analysis method is established at the 3 rd stage. The fourth stage is the collective meaning; historiography provides the overall picture through a narrative of the researcher's interpretation derived from the participants' expressions in an integrated story. At the 4 th stage, secondary data sources (newspapers, books, articles, and others) are commonly used to better reconstruct the stories. In this study, narratives were used to present the results based on each category and subcategories.
Researchers focused on a deeper understating of the phenomena through data triangulation, long-term involvement, and data immersion. Date collection and analysis lasted a year from September 2013 to November 2014. External and internal criticism was applied to increase data credibility, verify data genuineness, authenticity, and accuracy. The researchers initially tried to use resources that could verify data validity and if the research team could not validate a resource, the logical deduction was used to confirm or deny the content. After reviewing data and implementing the preliminary content analysis, findings were returned to the participants for confirmation of data accuracy. Moreover, the final versions of narratives retrieved from coded data to develop categories were evaluated by research supervisors and two peer experts in terms of clarity and accuracy. To establish recall related accuracy, individual statements were compared with the whole of the interview and with other interviews, and with the existing historical documents of that time period. These steps activated internal criticism of primary resources. It should be mentioned that participants' anonymity and confidentiality of the information provided and documents presented were strictly observed throughout the data collection and analysis process.

Results
Among the 14 participants, there were 11 women and 3 men, whose ages ranged from 53 to 93 years with the mean age of 67 ± 6 years. Among them, 4 had clinical nursing experience, 4 had managerial experience, and the rest were nurse educators from 7 different cities in Iran. We found that within the past century, sociopolitical events had a significant influence on the Iranian nursing profession and researchers were able to identify the 3 main categories of the White Revolution, the Islamic Revolution, and Iran-Iraq war.
The category of the White Revolution consisted of the subcategories of the Literacy Corps, Health Corps, and gradual formation of the nursing profession.
The category of the Islamic Revolution consisted of the subcategories of restructuring of higher education, and changing the culture of scientific and administrative systems. In addition, the Iran-Iraq war category consisted of the subcategories of the rebirth of nursing, facilitation of the admission of men into the nursing profession, and changing of the curriculum in response to needs.

The White Revolution
After the Second World War (WWII), and due to the changes in the western forum, the second Pahlavi king (

Facilitating admission of men into nursing
War had a major impact on the Iranian nursing profession and facilitated admission of men into the nursing profession. Before the revolution, few Iranian men were interested in nursing and some of them were educated during their military training.
After the Islamic Revolution, enrolling male applicants into a female dominated nursing program was a challenging prospect. More male nurses were needed, especially during and after the Iran-Iraq war. Male nurses found a special opportunity for progress in the nursing profession and were quickly promoted to higher positions even without sufficient training or work experience. Male nursing students were sent to war after completing their basic training and they gained significant first hand clinical experiences at the frontline. Hence, war played an important role in the Iranian nursing education and practice.
[At first, men were not easily accepted in nursing programs and later society recognized the need for having male nurses as an important part of the

Discussion
This study aimed to review the history of nursing in Iran within a sociopolitical context by interviewing senior nurses who lived through the changes. Developmental progress in nursing is not independent of social events. In this respect, Meleis stated that nursing discipline is a dynamic profession that moves toward novel social changes to meet needs and social demands, albeit, from popular movements, healthcare reforms, or global changes (16). Similar to other performance-based human and social sciences, nursing is not separate from conceptual practices of power, and economic, cultural, and political forces shaping science, philosophy, and knowledge development (17). Based on the findings of this study, the White Revolution in Iran was one of the most effective ways to help a struggling nation with literacy and health issues. Implementation of Literacy Corps and Health Corps was a step toward the integration of nursing profession in Iran. Governmental supports and the establishment of charitable unions also improved nursing in Iran. With these social progresses and governmental efforts, nursing was introduced as a legitimate profession to the Iranian society.
Steppe conducted a similar historical study in Germany to examine changes in nursing during the Nazi era and found that German nurses made significant changes in their profession to conform to the Nazi regime (18). At that time, external forces made improvement in social status, unity, and integrity within professional nursing organizations, developed effective nursing laws, and politicized the profession. Moreover, nurses observed ethical and professional principles to provide care without the surrounding social influences. Overall, Steppe argued that advances in nursing could never occur in a neutral and valueless context and are always affected by dominant social forces (18).
In this study, we found that pre-revolution governmental plans, such as the White Revolution during the Pahlavi Dynasty, had a direct influence on nursing education and practice regarding the attraction of girls from higher socioeconomic ranks into the profession. Nonetheless, sociocultural beliefs prevented religious and traditional families from allowing their daughters to pursue nursing. Another historical and sociopolitical change in Iran was the Islamic and Cultural Revolution, during which the ideologies of Iran's leadership brought about structural variations in beliefs and nursing values. Kent-Wilkinson stated that social movements, media events, technological progress, and change in public policies can affect training and development, and lead forensic nursing toward a new direction (19). In this study, religious and cultural changes showed quantitative and noteworthy improvement in nursing after the Islamic Revolution. Iranian families welcomed the religious and cultural changes after the revolution, and nursing profession succeeded in meeting the nation's needs for healthcare services. On the other hand, some of the overzealous lowranking government authorities and instructors imposed rigid requirements upon nursing students and nurses by demanding adaptation to their own ideologies; thus, immediately after the revolution, the quality of nursing education and practice suffered. In this regard, Tabari and Deans stated that one of the main challenges in nursing after the Islamic Revolution was the integration of religious beliefs into the nursing curriculum to meet the societs's spiritual needs through gender-appropriate care (4). As Fooladi reported, nursing programs were gender segregated and the faculty had to divide the curriculum for teaching male and female students in separate sessions, especially in simulation labs and clinical practice (6). To date, such gender sensitivities continue to be regarded and accepted as the Iranian public at large welcome such nursing care provisions through same-gender care; thus, witnessing an increase in male enrolment in nursing (4). Since religiosity has always been a part of the Iranian culture, the Islamic Revolution simply added a new dimension with a significant effect on women's rights for higher education, genderappropriate healthcare and acceptance of men in nursing (6). Overall, the nursing profession in Iran has been positively and negatively affected due to a cyclical path toward religion and cultural sensitivity (20). With respect to structural changes, transferring of nursing education to universities of medical sciences, gender equality in nursing education, expansion of nursing schools throughout the country, and the development of postgraduate education were among the advances in nursing after the Islamic Revolution. These changes helped form a better social image for the nursing profession due to academic rigor and satisfy cultural beliefs leading to higher student enrolment in nursing. Quantitative development of nursing was one of the considerable changes after the Islamic Revolution. The results of a study by Farsi et al. demonstrated that, in recent decades, increase in the number of male nursing students, development of postgraduate education, and introduction of the nursing profession to families improved the social image of nursing (21). The Iran-Iraq war had a significant effect on the way Iranian nurses performed and later were perceived by the authorities as important healthcare professionals. Cuellar disclosed that in spite of difficulties, nurses used the war as an opportunity to change their image (1). Improved public view towards nursing as well as the need for more men in nursing attracted more male candidates to Iranian nursing programs. During 1985 to 1988, almost 50% of applicants for B.Sc. in nursing were men, and after the war, the number dropped to less than 20% (22). Being at the frontline was viewed as a religious duty and a personal commitment. Others considered going to war as masculine responsibility to defend the country and help the injured soldiers. In previous studies, it has been reported that wars demanded more male nurses and increased male applicants in nursing programs (23). This does not mean female nurses had any less impact on patient care during wars, because female nurses' contributions in military hospitals and frontlines remain undeniable. In fact, study findings by Firouzkouhi et al. indicated that during the Iran-Iraq war, female nurses exhibited their advanced clinical and managerial skills (24). For the limited medical supplies, female nurses used their critical thinking skills and offered services while gaining military and clinical experiences (24). Peyrovi et al. revealed another aspect of war, by referring to the shortage of human resources after the Islamic Revolution, and social changes exhausting all other resources during the Iran-Iraq war (23). Similarly, we found that the nursing profession responded to national events by changing the curriculum and graduating more ADN instead of B.Sc. nurses to meet the nation's healthcare needs. Nursing has always been responsive to social changes and had a historical relationship with social development, and been determined by religious eras, legacy of wars, and appointed rules to meet patient satisfaction. In each society, health and healthcare ideologies are reflected through welfare and care. Nursing and its developments have been an integral part of any healthcare system.

Conclusion
This historical review aimed to describe the Iranian nursing profession and examine the sociopolitical events in Iran to find possible influences on nursing. The three major sociopolitical occurrences were the White Revolution, the Islamic Revolution, and the Iran-Iraq war. These events had significant impacts on the Iranian education, healthcare, and nursing profession. Nursing profession showed immense response to sociopolitical events due to having a close relationship with society. Iranian nurses showed professional and personal growth and evolved with new challenges and opportunities. Development in the Iranian nursing profession did not occur in isolation, and sociopolitical factors had a major influence through mutual understanding between nursing and society. Political decisions and sociocultural movements required changes in healthcare policies to accommodate the new ideological and philosophical structure. Healthcare policies at the governmental levels ultimately modified previous missions with new goals within the nursing profession. Events such as wars and Islamic and Cultural Revolution changed the healthcare practice and moved it toward a gender-appropriate system. Moreover, better planning through modifications in nursing curriculum was required to comply with the new rules. Sociopolitical events in Iran played a major role in advancing the nursing profession through policy changes in education, practice, research, and future plans. The nursing profession continues to develop and revise policies to improve the healthcare system and quality of patient care. The results of this study can help in the better understanding and consideration of sociopolitical impacts on the nursing profession when developing new healthcare policies.

Limitation
The loss of historical documents and subsequent lack of adequate access to essential resources were the main limitations in this study and were substituted with candid recalls and personal interviews with participants who lived through the previous era and witnessed changes as a professional nurse.